SF-36健康自測量表

TermsandConditionsforUsingthe36-ItemShortFormSurvey(SF-36)http://www.rand?org/health/surveys_tools/mos/36-item-short-form?html―,使用說明RANDherebygrantspermissiontouseRAND36-ItemShortFormHealthSurveyinaccordaneewiththefollowingconditions,whichshallbeassumedbyalltohavebeenagreedtoasaeonsequeneeofacceptingandusingthisdocument:ChangestotheHealthSurveymaybemadewithoutthewrittenpermissionofRAND.However,allsuchchangesshallbeclearlyidentifiedashavingbeenmadebytherecipient.TheuserofthisHealthSurveyacceptsfullresponsibility,andagreestoindemnifyandholdRANDharmless,fortheaccuracyofanytranslationsoftheHealthSurveyintoanotherIanguageandforanyerrors,omissions,misinterpretations,orconsequencesthereof.TheuserofthisHealthSurveyacceptsfullresponsibility,andagreestoindemnifyandholdRANDharmless,foranyconsequencesresultingfromtheuseoftheHealthSurvey.Theuserofthe36-ItemHealthSurveywillprovideacreditlinewhenprintinganddistributingthisdocumentacknowledgingthatitwasdevelopedatRANDaspartoftheMedicalOutcomesStudy.NofurtherwrittenpermissionisneededforuseofthisHealthSurv二，英文量表/health/surveys_tools/mos/36-item-short-form/survey-instrument.htmlRAND36-ItemHealthSurvey1.0QuestionnaireItemsSF-36ResourcesTermsandConditionsforUsingtheSF-36MOS36-ItemShortFormSurveyInstrument(SF-36)(EnglishPDF)MOS36-ItemShortFormSurveyInstrument(SF-36)(ArabicPDF)ScoringInstructionsforMOS36-ItemShortFormSurveyInstrument(SF-36)Chooseoneoptionforeachquestionnaireitem?Ingeneral,wouldyousayyourhealthis:J1-ExcellentJ2-VerygoodJ3-Good4-FairJ5-PoorComparedtooneyearago,howwouldyourateyourhealthingeneralnow?J1-MuchbetternowthanoneyearagoJ2-SomewhatbetternowthanoneyearagoJ3-Aboutthesame4-SomewhatworsenowthanoneyearagoJ5-MuchworsenowthanoneyearagoThefollowingitemsareaboutactivitiesyoumightdoduringatypicalday.Doeyourhealthnowlimityouintheseactivities?Ifso,howmuch?Yes,limitedlotaYes,limitedaNo,notlimitedatlittleall3.Vigorousactivities,suchasrunning,liftingheavyobjects,participatingin 廠C rCrstrenuoussports1234.Moderateactivities,suchasmovingatable,pushingavacuumcleaner,bowling,orrrplayinggolf1235.Liftingorcarryinggroceriesccc1236.Climbingseveralflightsofstairsccc1237.Climbingoneflightofstairsccc1238.Bending,kneeling,orstoopingccc1239.Walkingmorethanamile廣廣廣123Yes,limitedaYes,limitedaNo,notlimitedatlotlittleall10.Walkingseveralblocksr-廣廣*12311.Walkingoneblockr-廣廣*12312.Bathingordressingyourselfccc123Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofyourphysicalhealth?YesNoCutdowntheamountoftimeyouspentonworkorotheractivities12Accomplishedlessthanyouwouldlike12Werelimitedinthekindofworkorotheractivities12Haddifficultyperformingtheworkorotheractivities(forexample,ittookextraeffort)12Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofanyemotionalproblems(suchasfeelingdepressedoranxious)?YesNoCutdowntheamountoftimeyouspentonworkorotheractivities12Accomplishedlessthanyouwouldlike1 2Didn'tdoworkorotheractivitiesascarefullyasusual1 2Duringthepast4weeks,towhatextenthasyourphysicalhealthoremotionalproblemsinterferedwithyournormalsocialactivitieswithfamily,friends,neighbors,orgroups?J1-NotatallJ2-SlightlyJ3-ModeratelyJ4-Quiteabit5-5-ExtremelyHowmuchbodilypainhaveyouhadduringthepast4weeks?J1-NoneJ2-Verymild3-MildJ4-ModerateJ5-SevereJ6-VerysevereDuringthepast4weeks,howmuchdidpaininterferewithyournormalwork(includingbothworkoutsidethehomeandhousework)?J1-NotatallJ2-AlittlebitJ3-ModeratelyJ4-QuiteabitJ5-ExtremelyThesequestionsareabouthowyoufeelandhowthingshavebeenwithyouduringthepast4weeks.Foreachquestion,pleasegivetheoneanswerthatcomesclosesttothewayyouhavebeenfeeling.Howmuchofthetimeduringthepast4weeks...AlloftimetheMostoftheAgoodbitoftheSomeoftheAlittleoftheNoneofthetimetimetimetimetime23.Didyoufeelfullofpep?12345624.Haveyoubeenaverynervousperson?12345625.Haveyoufeltsodowninthedumpsthatnothingcouldcheeryouup?

AlloftimetheMostoftheAgoodbitoftheSomeoftheAlittleoftheNoneofthetimetimetimetimetime26.Haveyoufeltcalmandpeaceful?廣r-(-(-r-廣12345627.Didyouhavealotofenergy?廣廣廣廣廣廣12345628.Haveyoufeltdownheartedandblue?廣廣廣廣廣廣12345629.Didyoufeelwornout?廠廣廣廣廣廣12345630.Haveyoubeenahappyperson?cccccc12345631.Didyoufeeltired?廣廣廣廣廣廣12345632.Duringthepast4weeks,howmuchofthetimehasyourphysicalhealthoremotionalproblemsinterferedwithyoursocialactivities(likevisitingwithfriends,relatives,etc.)?J1-Allofthetime2-MostofthetimeJ3-SomeofthetimeJ4-AlittleofthetimeJ5-NoneofthetimeHowTRUEorFALSEiseachofthefollowingstatementsforyou.33.IseemtogetsickalittleeasierthanotherpeopleDefinitelytrue1Mostlytrue2Don'tknow3Mostlyfalse4Definitelyfalse534.IamashealthyasanybodyIknowr-f-r-r~r-1234535.Iexpectmyhealthtogetworser-Cr-CC1234536.Myhealthisexcellentr-r-r-r-r-12345健康狀況調(diào)查問卷（SF-36）及其使用說明健康狀況調(diào)查問卷（SF-36）以下問題是詢問您對自己健康狀況的看法，您自己覺得做日常活動的能力怎么樣。如果您不知如何回答是好，就請您盡量給出最好的答案，并在本問卷最后的空白處寫上你的注釋與評論。請丿一個答案1?總體來講，您的健康狀況是：非常好很好O好O一般O差O2?跟一年前相比，您覺得您現(xiàn)在的健康狀況是：比一年前好多了O比一年前好一些O跟一年前差不多O比一年前差一些O比一年前差多了O健康和日常活動□3?以下這些問題都與日?；顒佑嘘P。請您想一想，您的健康狀況是否限制了這些活動？如果有!限制，程度如何？ 請在每二行《二個答案 i…一有限制有限制毫無I 限制很左……有些限制―…限制…丄…一（1）重體力活動，如：跑步、舉重物、參加劇烈運動等 O O o.口（2） 適度的活動，如：移動一張桌子、掃地、打太極拳、做簡單體操等 O O O!口匚3）手提旦用品，…如買菜、購物等（4）上幾層樓梯 （一5）…上二層樓梯 .9）…彎腰、曲膝、…下蹲 （7）步行1600m.以上的路程.……____（一8）…步行800m的路程 （9）步行100m的路程TOC\o"1-5"\h\zO O O...上O O O. □o o O. □o o O. □o o 0一...上對每條問題請回答“是”或“不是”是 不是(1)減少了工作或活動的時間O O□(2)本來想要做的事情只能完成一部分O O□(3)干事情不如平時仔細O O!1□6?在過去的四個星期里，你的健康或情緒不好在多大程度上影響了您與家人、朋友、鄰居或集體的正常社會交往？請丿一個答案：安全沒影響Oi有一點影響O中等影響OIi□影響很大O11影響非常大O7?過去四個星期里，您有身體疼痛嗎？完全沒有疼痛O稍微有一點疼痛OI有一點疼痛OI中等疼痛OI□嚴重疼痛O11很嚴重疼痛Oi8?過去四個星期里，身體上的疼痛影響你的工作和家務事嗎？完全沒有影響o!有一點影響Oi中等影響O口影響很大Oi影響非常大OI您的感覺9?以下這些問題有關過去一個月里您自己的感覺,對每一條問題所說的事情，你的情況是什么樣的？請圈出最接近您的情況的那個答案。請在每一條問題后丿出一個答案持續(xù)的時間 所有的大部分比較多一部分 一小部沒有這i時間時間時間時間 分時間種感覺i(1)您覺得生活充實 OOOO OOIi口(2)您是一個敏感的人 OOOO O 0 j

(10)不健康影響了您的社會活動(如走親訪 O O O O O O友等)總體健康情況10?請看下列每一條問題，哪一種答案最符合您的情況？ I請在每一條問題后丿一個答案絕對 大部分 不能 大部分 絕對正確 正確 肯定 錯誤 錯誤 1(I)我好像比別人容易生病 O O O O Oi□(2)我跟周圍人一樣健康 O O O O O—(3)我認為我的健康狀況在 1O O O O O i變壞 i1□(4)我的健康狀況非常好 O O O O O□如果您有注釋或評論，請寫在下面：非常感謝您的合作！請按要求將這份表填好后交還給我們評分原則：(I)該量表為MOS-SF36生存質(zhì)量量表中文版。(2)評分原則是分量表及各條目積分越